GSIS Form No.

FUNERAL-2011-04-001
11-04-001

PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN

(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila 1308

REPUBLIC OF THE PHILIPPINES)

) S. S.
-------------------------------------)

Affidavit for Refund of Funeral Expenses

This Affidavit is to be executed if the claimant is other than the surviving

spouse.

I, ____________________________________________________________________, of
legal age, married/single and residing at
___________________________________________,
after having sworn in accordance with law, hereby depose and state:

1. That I am the ________________ of the late

______________________________________,
who was insured in the Government Service Insurance System and died
on
_______________________________;
2. That I took charge in the interment of the above-mentioned deceased member and
as
such I was responsible for the burial expenses incidental thereto;

3. That the following burial expenses were incurred in the interment of the
deceased:

Funeral service P
Cemetery lot
Burial permit
Coffin
Music
Food & Drinks (served to the people who came to
condole with the bereaved family)
Church rites
Tomb
Miscellaneous
TOTAL P

_____________________________________
Affiant

CORROBORATION
We, the undersigned, Filipinos, of legal age and with postal address
indicated below
our signatures, after having duly sworn to in accordance with law depose and say:
 That having personal knowledge of the facts of the death of the insured
Mr./Mrs./Ms._____________________________________________, who died
on
______________________ at ___________________________________, do hereby declare
and
confirm the truth of the statements made herein by claimant/affiant.

___________________________________
___________________________________
Signature of Witness Signature of Witness

Address: Address:

________________________________________
_______________________________________
 Subscribed and sworn to before me this _______ day of _________________,
20___ in
the city of Pasay, Philippines, affiant(s)/witness(es) exhibiting to me,
respectively, their
Community Tax Certificates and the following valid government identifications:

Name CTC No. Place of Issue

Date Issued

NOTARY PUBLIC
Doc. No. _________
Page No.__________
Book No.__________
Series of 201______
Expiry date: December 31, _______